Tara A. Dullye,
M.D., F.A.C.O.G.
MEDICAL RECORDS RELEASE FORM
Physician
or facility from whom
records are requested:
Release records to:
Name: _______________________________________
Tara A. Dullye, M.D.
Address: ______________________________________
8160 Walnut Hill Lane #219
______________________________________________
Dallas, Texas 75231
Phone No.: ___________________________________
Fax: (214) 369-7528
Fax No.: __________________________________
Patient (name at time of prior treatment):
____________________________________________
Patient date of birth: _____________________________
This authorizes you to provide a
copy, summary, or narrative of my medical records - as indicated by the
checkmark(s) below - or otherwise release confidential information.
Complete record
Records of care for dates: __________________________
to: _____________________________
Records concerning the following condition(s):
__________________________________________
Confer orally with Dr. Tara Dullye or her
staff about my medical information
Other (please specify):
_______________________________________________________________
The reasons or purposes for this release are
as follows:
For continuing patient care,
diagnosis, evaluation and treatment
For emergent care of this patient
Other:
___________________________________________________________________________
Patient
signature: _____________________________________
Date:_______________________